Definitions
Peripheral Venous Lactate Level
50 pts - Define lactate
"A level above __ mmol/L is associated with a __% mortality rate"
Lactate is a marker for cellular hypoxia.
4.0, 27%
Name the four Shock classifications
Hypovolemic
Cardiogenic
Obstructive
Distributive
Name all stages of shock
Stage I: Initiation
Stage II: Compensatory
Stage III: Progressive
Stage IV: Refractory
Hypovolemic shock
SKIN: Pale, waxen, ashen, cool, mottled
NECK VEINS: Collapsed
CAPILLARY REFILL: >3 seconds
PULSES: Weak & thready
AFTERLOAD (SVR): Increased
PRELOAD (RAP): Decreased
CO: Decreased
Compensated Map: Normal
Decompensated Map: Decreased
Septic shock
qAntibiotic therapy
qRemoval of septic focus when possible
qCooling measures for T > 102 o F
qGlucocorticoids to reduce inflammatory response (controversial)
What are the predisposing factors of septic shock. (6)
Translation: What risk factors make a person more susceptible to get septic shock
Elderly
Immunocompromised
Invasive procedures, indwelling catheters
Neonates
Alcoholics
Diabetics
Hypovolemic Shock Etiology and Underlying Pathology
Etiology: Hemorrahage, Burns
Underlying Pathology: Whole blood loss, plasma loss
Describe Stage 2
(2 bullets)
Sustained reduction in tissue perfusion
Initiation of compensatory mechanisms
–Neural: baroreceptors and chemoreceptors
–Endocrine: ACTH and ADH
–Chemical
»Low oxygen tension
»Hyperventilation and respiratory alkalosis
Septic Shock HYPOdynamic phase
+100 pts for hemodynamics
qHypothermia
qWorsening LOC
qDecreased WBC’s
qOliguria
qHypoglycemia
qHypotension
qTachycardia
qTachypnea
qMetabolic Acidosis
qCool, pale skin
Hemodynamics
qMAP: Decreased
qAFTERLOAD (SVR): Increased, decreased, or normal
qPRELOAD (RAP): Increased, decreased, or normal
qCO: Decreased
Hypovolemic Shock (500 pts potential)
+100pts
What do you give considering how much cc of blood loss
+ 200 pts
What do you give a patient who lost more than 1500 cc of blood
ABC’s first
Identify & control the source of the fluid/blood loss
VOLUME, VOLUME, VOLUME!!!
Vasopressors should be avoided until replacement of the volume loss is well under way
DEHYDRATION
Electrolyte solution, i.e., LR
HEMORRHAGE
>1000-1250 cc blood loss
3 cc of crystalloid for every 1 cc of blood loss
OR
1 cc of colloid (blood products, albumin, etc.) for every 1 cc blood loss
< 1500 cc blood loss
Crystalloid plus blood components
Define Shock
150 pts for definition
150 pts for "__ ___ ___ __ ___"
Inadequate perfusion at the tissue level resulting in a decreased supply of O2 and nutrients required to maintain the metabolic needs of the body
“The reversible stage of dying.”
Cardiogenic shock Etiology and Underlying Pathology
Etiology: MI, Dysthymia's, Myocardial contusion
Underlying Pathology: loss of cardiac contractility, reduced CO
Describe stage 1
(1 bullet)
Hypoperfusion: inadequate delivery or extraction of oxygen
-No obvious clinical signs
-Early, reversible
Septic Shock HYPERdynamic Phase
+100 for hemodynamics
qTachycardia
qWarm, flushed skin, hyperthermia
qAltered LOC
qPolyuria
qIncreased WBC’s
qHyperglycemia
qDilated intravascular compartment
q“Leaky” vascular compartment
qHypotension
qTachypnea, respiratory alkalosis
Hemodynamics:
qMAP: Normal or decreased
qAFTERLOAD (SVR): Decreased
qPRELOAD (RAP): Normal or decreased
qCO: Increased
Anaphylactic Shock
qABC’S
qEpinephrine 3-5 cc of 1:10,000 IV push
qEpiPen (outside of hospital setting)
qCrystalloids or albumin
qVasopressors for persistent hypotension
Obstructive Shock Etiology and Underlying Pathology
Etiology: Cardiac Tamponade, Tension pneumothorax or hemothorax
Underlying Pathology: Heart compression with obstruction to atrial filling, Mediastinal shift with obstruction to atrial filling
Describe stage 3
(5 bullets)
Progressive
Increased capillary hydrostatic pressure
Intravascular fluid shifts
–Interstitial edema
–Decreased circulating intravascular volume
Decreased coronary perfusion
–Myocardial depressant factor released
–Decreased myocardial contractility
Failure compensatory mechanisms
Profound CV cardiovascular effects
–Increased hypoperfusion
–Vasoconstriction
»Extremity ischemia
»Cellular hypoxia
»Lactic acid production
»Failure Na+/K+ pump
Neurogenic Shock
+100 hemodynamics
qWarm, pink, dry skin
qBradycardia
qNormal or weak pulses
qHypoventilation or apnea
qPoikilothermy
qMassive vasodilation
qPooling of blood in peripheral circulation
qRelative hypovolemia
qAltered LOC
HEMODYNAMICS
qMAP: Decreased
qAFTERLOAD (SVR): Decreased
qPRELOAD (RAP): Decreased
qCO: Normal or decreased
Neurogenic Shock
qABC’s
qCrystalloids
qElevation of lower extremities
qControl of severe symptomatic bradycardias
Distributive Shock Etiology and Underlying Pathology
Etiology: Neurogenic shock, Anaphylactic shock, Septic Shock
Underlying Pathology: Venous pooling, Shunting in microcirculation and decreased venous resistance in later stages
Describe stage 4
(6 bullets)
Prolonged inadequate tissue perfusion
–Unresponsive to therapy
–Contributes to multiple organ dysfunction and death
Thrombi in microcirculation
Metabolic acidosis
Vasomotor failure
Decreased coronary perfusion leading to decreased myocardial contractility
Tissue ischemia
Anaphylactic shock
+100 hemodynamics
qLaryngeal edema
qDyspnea
qStridor
qWheezing
qLower airway obstruction
qRetractions
qPulmonary Edema
qN/V/D, abdominal cramping
qAltered LOC
qWarm/flushed skin
qAshen in later stages
qEdema of subcutaneous or mucus tissues
qItching, hives
qTachycardia
qWeak, thready pulse
HEMODYNAMICS
qMAP: Decreased
qAFTERLOAD (SVR): Decreased
qPRELOAD (RAP): Decreased
qCO: Normal or decreased